Context

The lesson emerging from the pandemic experience is that if India does not want a repeat of the immeasurable suffering and the social and economic loss, we need to make public health a central focus.

Need for institutional reforms in the health sector

• The importance of public health has been known for decades with every expert committee underscoring it.
• Ideas ranged from instituting a central public health management cadre like the IAS to adopting an institutionalised approach to diverse public health concerns — from healthy cities, enforcing road safety to immunising newborns, treating infectious diseases and promoting wellness.
• Covid has shifted the policy dialogue from health budgets and medical colleges towards much-needed institutional reform.

About National Health Mission (NHM)

• The National Health Mission (NHM) seeks to provide universal access to equitable, affordable and quality health care which is accountable, at the same time responsive, to the needs of the people, reduction of child and maternal deaths as well as population stabilization, gender and demographic balance.
• The Framework for Implementation of NUHM has been approved by the Cabinet on May 1, 2013.
• NHM encompasses two Sub-Missions, National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
• The National Rural Health Mission (NRHM) was launched in 2005 with a view to bringing about dramatic improvement in the health system and the health status of the people, especially those who live in the rural areas of the country.

Learning from the failure of National Health Mission (NHM)

• The National Health Mission (NHM) has been in existence for about 15 years now and the health budget has trebled— though not as a proportion of the GDP.
• Despite this less than 10 per cent of the health facilities below the district level can attain the grossly minimal Indian public health standards.
• Clearly, the three-tier model of subcentres with paramedics, primary health centres with MBBS doctors and community health centres (CHC) with four to six specialists has failed.
• Lack of accountability framework: The model’s weakness is the absence of an accountability framework.
• The facilities are designed to be passive — treating those seeking care.

Suggestions

• 1] FHT: Instead of passive design of NHM, we need Family Health Teams (FHT) like in Brazil, accountable for the health and wellbeing of a dedicated population, say 2,000 families.
• The FHTs must consist of a doctor with a diploma in family medicine and a dozen trained personnel to reflect the skill base required for the 12 guaranteed services under the Ayushman Bharat scheme.
• A baseline survey of these families will provide information about those needing attention.
• Family as a unit: The team ensures a continuum of care by taking the family as a unit and ensuring its well-being over a period.
•  Nudging these families to adopt lifestyle changes, following up on referrals for medical interventions and post-operative care through home visits for nursing and physiotherapy services would be their mandate.
• 2] Health cadre: The implication of and central to the success of such a reset lies in creating appropriate cadres.
• 3] Clarity to nomenclatures: There is also a need to declutter policy dialogue and provide clarity to the nomenclatures.
• Currently, public health, family medicine and public health management are used interchangeably.
• While the family doctor cures one who is sick, the public health expert prevents one from falling sick.
• The public health management specialist holds specialisation in health economics, procurement systems, inventory control, electronic data analysis and monitoring, motivational skills and team-building capabilities, public communication and time management, besides, coordinating with the various stakeholders in the field.
• 4] Move beyond doctor-led systems: India needs to move beyond the doctor-led system and paramedicalise several functions.
• Instead of wasting gynaecologists in CHCs midwives (nurses with a BSc degree and two years of training in midwifery) can provide equally good services except surgical, and can be positioned in all CHCs and PHCs.
• This will help reduce C Sections, maternal and infant mortality and out of pocket expenses.
• 5] Counsellors and physiotherapists at PHC: Lay counsellors for mental health, physiotherapists and public health nurses are critically required for addressing the multiple needs of primary health care at the family and community levels.
• 6] Review of existing system: Bringing such a transformative health system will require a comprehensive review of the existing training institutions, standardising curricula and the qualifying criteria.
• Increase spending on training: Spending on pre-service and in-service training needs to increase from the current level of about 1 per cent.
• 7] Redefining of functions: A comprehensive redefinition of functions of all personnel is required to weed out redundancies and redeploy the rewired ones.

Conclusion

Resetting the system to current day realities requires strong political leadership to go beyond the inertia of the techno-administrative status quoist structures. We can.

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